Client Agreement & ​Physical Activity Readiness Questionnaire (PAR-Q)

Client Details

Client Readiness for Activity

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

YesNo

Do you feel pain in your chest when you perform physical activity? *

YesNo

In the past month, have you had chest pain when you were not performing any physical activity? *

YesNo

Do you lose your balance because of dizziness or do you ever lose consciousness? *

YesNo

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

YesNo

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

YesNo

Do you know of any other reason why you should not engage in physical activity? *

YesNo

If you have answered YES to one or more of the above questions, consult your doctor before engaging in physical activity. Tell your doctor which questions you answered YES to. After medical evaluation, seek advice from your doctor on what type of activity is suitable for your current condition. *

I understand

General & Medical History

Occupational

What is your current occupation? *

Does your occupation require extended periods of sitting? *

YesNo

DOES YOUR OCCUPATION REQUIRE REPETITIVE MOVEMENTS? *

YesNo

If YES, please explain. (If NO, type N/A) *

DOES YOUR OCCUPATION REQUIRE YOU TO WEAR SHOES WITH A HEEL (E.G., DRESS SHOES)? *

YesNo

If YES, please explain. (If NO, type N/A) *

Does your occupation cause you mental stress? *

YesNo

If YES, please explain. (If NO, type N/A) *

Recreational

Do you partake in any recreational physical activities? Golf, running, going to the gym, etc. *

YesNo

If YES, please explain. (If NO, type N/A) *

DO YOU HAVE ANY ADDITIONAL HOBBIES? READING, VIDEO GAMES, ETC. *

YesNo

If YES, please explain. (If NO, type N/A) *

Medical

HAVE YOU EVER HAD ANY INJURIES OR CHRONIC PAIN? *

YesNo

If YES, please explain. (If No, type N/A) *

HAVE YOU EVER HAD ANY SURGERIES? *

YesNo

If YES, please explain. (If No, type N/A) *

HAS A MEDICAL DOCTOR EVER DIAGNOSED YOU WITH A CHRONIC DISEASE, SUCH AS HEART DISEASE, HYPERTENSION, HIGH CHOLESTEROL, OR DIABETES? *

YesNo

If YES, please explain. (If No, type n/a) *

ARE YOU CURRENTLY TAKING ANY MEDICATION? *

YesNo

If YES, please explain. (If no, type n/a) *

Additional Information

Is there any else you think I may need to know that may effect your ability to train. (This is of course in total confidence). *

Client Agreement

Appointment times will be mutually agreed with your trainer Edd Power. Your contact details are securely held by your personal trainer and will remain confidential. Training sessions are 60 mins in length. You will arrive on time for your session in appropriate clothing and ready to train as sessions can’t be delayed beyond their scheduled time. *

I understand

If you do not give 24 hours notice of cancellation, you be charged for that session.If you do not attend your booked session you will be charged for that session. If you are late for a session it will still end at the scheduled time. All sessions must be paid for in advance. *

I understand

I have agreed to undertake in a programme of physical exercise under the instruction of Edd Power from Empower Fitness. Training may include, but is not limited to, weight and/or resistance training, cardiovascular training, and floor mat exercises. Edd Power from Empower Fitness agrees to instruct, assist and train me. I realise that a large portion of my success will be based on my commitment to follow instruction, changing my lifestyle, and my attitude towards the fitness programme. Unfortunately Empower Fitness cannot guarantee results, but my willingness to work hard will improve the opportunity of success. I have read the above policy and agree to its terms as it applies to my personal training package. *

I agree

By clicking ‘I agree’ & submitting this completed form, you confirm that you have read, understood and completed the PAR Questionnaire and answered all questions truthfully, to the best of your knowledge. *